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To be completed by the Employee
Name
J#
Job Title
Hire Date
Current Date
Supervisor's Name
Separation Date
Please indicate the academic or administrative unit or department where you work at the University.
Position Type:
Faculty
Staff
Were you a full-time or part-time employee?
Full-time
Part-time
How many years did you work for JSU?
0 - 2 years
3 - 5 years
6 - 10 years
11 - 15 years
16 - 20 years
21 + years
Type of separation:
Retirement
Resignation
Discharge
Layoff
What are your reasons for leaving the University?
I am leaving JSU to pursue a new job
Lack of recognition for work
Non-renewal of contract or position
Laid Off (RIF)
Family or personal needs
Dissatisfied with compensation
Relocation to another City
To further education
Discontinuation of funding
Dissatisfied with work conditions
I am retiring (Retirement)
Dissatisfaction with supervisor
Dissatisfied with benefits
Workload or work hours
Dissatisfaction with Co-Workers
Medical issues
Lack of advancement opportunities
Dissatisfied with type of work
In the space provided, please indicate the specific reason(s) for leaving the University.
How do you feel about the pay and benefits?
How do you feel about the pay and benefits?
Excellent
Good
Fair
Poor
Rate of Pay for your job.
Excellent
Good
Fair
Poor
Paid holidays
Excellent
Good
Fair
Poor
Paid vacation
Excellent
Good
Fair
Poor
Retirement Plan
Excellent
Good
Fair
Poor
Medical Coverage for Self
Excellent
Good
Fair
Poor
Medical Coverage for dependents
Excellent
Good
Fair
Poor
Life insurance
Excellent
Good
Fair
Poor
Sick Leave
Excellent
Good
Fair
Poor
Please rate the items below in terms of your satisfaction with each during your employment at JSU:
Please rate the items below in terms of your satisfaction with each during your employment at JSU:
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Type of Work
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Pay / Compensation
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Dental Benefits
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Vision Benefits
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Retirement Options
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Physical Working Conditions
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
My Manager(s) / Supervisors management method
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
My Co-Worker(s)
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Work Schedule
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Opportunities for Promotion or Career Advancement
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Professional Development Opportunities
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Work/Life Balance
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Recognition
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
The information you received on policies, programs, projects, and problems
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Performance review policies and practices
Very Unsatisfied
Unsatisfied
Satisfied
Very Satisfied
No opinion
Please indicate the degree to which you were satisfied with the following at JSU.
Please indicate the degree to which you were satisfied with the following at JSU.
Satisfied
Neutral
Dissatisfied
No Opinion
I understood how my job contributed to JSU's mission
Satisfied
Neutral
Dissatisfied
No Opinion
I had adequate resources to successfully perform my job at JSU.
Satisfied
Neutral
Dissatisfied
No Opinion
My contributions were recognized.
Satisfied
Neutral
Dissatisfied
No Opinion
I received regular feedback about my performance.
Satisfied
Neutral
Dissatisfied
No Opinion
My supervisor supported me in my work.
Satisfied
Neutral
Dissatisfied
No Opinion
I received sufficient training to do my job well.
Satisfied
Neutral
Dissatisfied
No Opinion
Is there anything additional that we did not ask you about that you feel is important for us to know?
Have you returned the following?
Keys
I.D./Supercard
American Express
Cell Phone
Electronic Devices
Uniforms
Access Keys
All Inventory
Laptops
Reports/Books/Manuals
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